Provider Demographics
NPI:1356755565
Name:KELLER, TRINA M
Entity type:Individual
Prefix:
First Name:TRINA
Middle Name:M
Last Name:KELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRINA
Other - Middle Name:
Other - Last Name:MCCON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-526-0177
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:18740 HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:MAUREPAS
Practice Address - State:LA
Practice Address - Zip Code:70449-3018
Practice Address - Country:US
Practice Address - Phone:225-698-3435
Practice Address - Fax:225-698-6446
Is Sole Proprietor?:No
Enumeration Date:2014-06-16
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07678363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA363566YPK7Medicare Oscar/Certification